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Legionnaires’

Disease Response
And Remediation At
The Illinois
Veterans’ Home At
Quincy

April 6, 2018
Table of Contents
Executive Summary ........................................................................................................ 1
I. Statements in HR 0726 Require Correction and Clarification ....................................... 3
II. IVHQ Background ....................................................................................................... 4
III. Clinical Background On Legionnaires’ Disease .......................................................... 4
A. Reported Cases of Legionnaires’ Disease Are On The Rise ............................. 5
B. People At Increased Risk .................................................................................. 6
C. Signs and Symptoms Are Similar to Other Respiratory Diseases ..................... 7
D. Diagnosis of Legionnaires’ Disease Should Use Rapid Urine Antigen Testing . 7
E. Treatment of Legionnaires’ Disease Is Similar to Other Pneumonias................ 8
F. The Bacteria That Causes Legionnaires’ Disease Is Ubiquitous ....................... 8
G. Legionella Spreads Through Water Systems, Which Makes City-Wide
Outbreaks Possible ................................................................................................ 9
IV. Baseline Epidemiology At IVHQ ................................................................................ 9
V. The Response To The Outbreak Followed CDC’s Best Practices And Reduced The
Spread Of Disease ........................................................................................................ 10
A. The Immediate Response Put Into Place Measures That Protected Patients
From Further Risk ................................................................................................ 11
B. The Epidemiological Response Is Designed To Find Common Sources Of
Exposure Among Cases ...................................................................................... 12
C. The Environmental Health Response Is Focused On Finding The Source Of An
Outbreak .............................................................................................................. 13
D. The Clinical And Infection Control Response Prevents Disease Transmission15
VI. IVHQ Residents And Employees Were Notified About Legionnaires’ Disease ........ 16
A. Residents Were Notified During Enhanced Vital Sign Screenings .................. 16
B. Employee Notification Included Education About Legionnaires’ Disease ........ 16
VII. Remediation Efforts Improved Water Quality And Significantly Reduced
Legionnaires’ Disease Cases ........................................................................................ 17
A. Remediation Steps Were Designed To Reduce Bacterial Levels And Risk of
Disease ................................................................................................................ 19
B. Potable Water Improvements Have Reduced The Risk of Legionnaires’
Disease ................................................................................................................ 19
C. Improvements To The Cooling Towers Reduced The Risk Of Aerosolized
Bacteria................................................................................................................ 20
D. Significant Infrastructure Improvements To Modernize The Water System ..... 20
VIII. Next Steps ............................................................................................................. 21

i
A. Ongoing Actions ............................................................................................. 21
B. Short-Term Actions ........................................................................................ 22
C. Long-Term Actions ......................................................................................... 22
IX. Timeline of Events ................................................................................................... 23
X. Appendices .............................................................................................................. 30
A. CDC Trip Reports ............................................................................................ 30
B. Case Summary Table ...................................................................................... 31
C. Geographic Distribution of Legionellosis in Illinois, 2014-2016 ....................... 32

ii
Executive Summary
In August 2015, the Illinois Veterans’ Home at Quincy (IVHQ) experienced an
unprecedented outbreak of Legionnaires’ disease. The outbreak led to a coordinated
local, state, and federal response that applied the best scientific practices to reduce the
sharp rise in cases. Since August 2015, the Adams County Health Department
(ACHD), the Illinois Department of Veterans’ Affairs (IDVA), the Illinois Department of
Public Health (IDPH), the Governor’s Office (GO), and the Centers for Disease Control
and Prevention (CDC) have worked to determine the source of the outbreak, improve
the water quality at IVHQ, and prevent further exposures. The quick, coordinated, and
comprehensive response to this outbreak has, according to the CDC, reduced the
number of Legionnaires’ cases and the amount of Legionella bacteria at IVHQ.

The tragic illnesses and deaths at IVHQ spurred a continuous quality improvement plan,
still in place, to eliminate Legionella risk at IVHQ. Since August 2015, local, state,
and federal agencies have dedicated themselves to protecting the health and
safety of Illinois’ veterans. Pursuant to H.R. 0726, this report chronicles the initial
response, as well as the subsequent remediation efforts that dramatically reduced
Legionella bacteria levels in the IVHQ water supply. This report also describes the
continuing efforts to ensure the safety of all residents and staff at IVHQ.

Across the United States, and in Illinois, Legionnaires’ disease rates continue to
rise. The disease presents a growing risk to susceptible individuals with
compromised immune systems, respiratory issues, and other health challenges,
like many IVHQ residents. The disease’s common clinical presentation paired with its
challenging diagnosis leaves cases underreported.

In any outbreak, the primary goal is to stop the sharp increase in cases to protect public
health. Once the outbreak was identified, the State of Illinois team began implementing
protective measures designed to reduce the risk of infection. Misconceptions around
perceived notification delays and lack of a clear plan have led to misunderstandings
around what different agencies do, how that work is accomplished, and most
importantly, how best to move forward. To correct those inaccuracies, this report
provides a transparent account of the response to the outbreak and the steps going
forward. In August 2015, state and local agencies applied CDC-approved
scientific interventions that reduced the risk to the residents. If Illinois had not
taken the quick, coordinated approach that it did in 2015, the number of cases would
most likely have been much higher.

Upon notification of a second confirmed case, IDPH implemented its response plan and
provided initial guidance to IVHQ within 27 minutes. IDPH continued to execute this
plan over the subsequent weeks with the following prevention and mitigation steps:
• Work with IVHQ to provide clinical, environmental, and epidemiological
recommendations to:
o Increase active clinical surveillance of cases and potential cases

1
o Discontinue operation of water systems that aerosolize Legionella
o Install point-of-use mitigation systems
• Determine who is at risk, from where are they at risk, and how to protect them
• Conduct water and environmental sampling and risk assessment of infrastructure
• Conduct regular meetings with CDC and other federal, state, and local partners

Following notification from IDPH, IVHQ implemented its own response to the cases,
including:
• Educating and informing staff within fewer than 15 hours of IDPH notification
• Informing residents of a respiratory illness spreading throughout the campus
within fewer than 15 hours of IDPH notification
• Informing powers of attorney—often a family member—of any health status
changes within three hours of symptom presentation and informing them about
Legionnaires’ disease upon notification of a positive test result
• Implementing IDPH/CDC scientific recommendations

Through an intensive investigation following the initial outbreak, and as documented by


CDC in its three comprehensive trip reports, federal, state and local officials have, in
retrospect, identified risks and vulnerabilities that were not known in 2015 when the
Legionella cases were originally identified. To address these findings, since 2015, IDVA
has invested $6.4 million in building a water treatment facility. IVHQ has implemented
all three expert-recommended approaches to water remediation: heat treatment,
chemical treatment, and water filtration. IVHQ also installed Pall filters on every shower,
tub, sprayer, icemaker, drinking fountain, and, most recently, sink faucet across the
campus to block Legionella bacteria. IDPH has requested CDC’s on-site expertise four
times and, together, the two public health agencies have provided specific scientific
recommendations to address the risk of Legionella.

With recent cases at IVHQ, IDVA, IDPH and CDC all remain committed to reducing
illness and preventing death from Legionella. Our work with the Illinois General
Assembly to secure appropriations, with the U.S. Congressional delegation to obtain
federal funding, and with local, state, and federal partners to implement prevention,
mitigation, and remediation efforts all continues. A draft report with recommendations
was submitted to members of the Water Management Task Force and the Infrastructure
Investment Task Force on March 31, 2018 for review, with a final plan to be submitted
on May 1, 2018. Any and every option remains on the table to serve Illinois’ veterans.

As the CDC notes, “Efforts by IDPH and IVHQ to control Legionella resulted in
substantially fewer Legionnaires’ disease cases” since 2015. 1 IVHQ, IDVA, and
IDPH, are committed, as always, to protecting the health and safety of all IVHQ
residents and staff.

1
Centers for Disease Control and Prevention. (2018). “Illinois Veterans Home Legionella Investigation —
Quincy, Illinois, 2017.” Retrieved from http://dph.illinois.gov/topics-services/diseases-and-
conditions/diseases-a-z-list/legionellosis, 11.

2
I. Statements in HR 0726 Require Correction and Clarification
The language and assertions included in H.R. 0726 require clarification and correction
for the record.

Page 1; Lines 15-17: WHEREAS, The first confirmed case of Legionnaires'


disease was found at the Illinois Veteran's Home at Quincy on July 24, 2015.

The first laboratory-confirmed case was not found on July 24, 2015. In retrospect, we
now know that July 24, 2015, is the date on which the first laboratory-confirmed case
began exhibiting symptoms of Legionnaires’ disease and was provided treatment. The
hospital collected the specimen from this resident on July 29, 2015, and laboratory
results were completed on August 3, 2015. On August 4, 2015, the hospital informed
ACHD, which, in turn, notified IVHQ on August 6, 2015.

A single case of Legionnaires’ disease does not constitute an outbreak, but does
warrant an investigation. ACHD began such an investigation and traced the case’s
whereabouts during the incubation period. Because the resident had left IVHQ to visit
the doctor, eat at restaurants, and take walks, ACHD could not determine whether the
resident acquired the infection at IVHQ.

Page 2; Lines 9 and 16 and Page 3; Line 1

The resolution mentions three people: Melvin Tucker, Gerald Kuhn, and Dolores
French. While their deaths are tragic, the description in the resolution, based on
pending litigation, is not complete and does not include the factual history of each case,
in its entirety. Because of the State’s obligation to protect patient privacy under the
federal Health Insurance Portability and Accountability Act (HIPAA), the State is not
able to disclose the medical and treatment history of these residents that would provide
the needed clarification.

Page 3; Lines 21-23 whether they should have publicized the outbreak earlier in
order to afford families the best chance to help their loved ones.

In suspected health care facility outbreaks, the responsibility of public health authorities
is to notify the facility. In this case, such notification was made 27 minutes after IDPH
was notified of a second confirmed case. It is the facility that can put into place
remediation measures that keep residents safe, with IDPH’s guidance. Here, IVHQ
instituted remediation measures, such as restricting exposure to aerosolized water, that
ultimately prevented further Legionnaires’ disease cases.

In addition, according to the CDC, "There is no vaccine for legionellosis, and antibiotic
prophylaxis is not effective." 2 Thus, the only scientifically known way to prevent

2
Kutty, P.K. and Garrison, L.E. (2017, May 31). Legionellosis (Legionnaires’ Disease & Pontiac Fever)
Retrieved from https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-
travel/legionellosis-legionnaires-disease-pontiac-fever

3
additional cases among those who had not already been exposed was to
implement the various measures that IDPH recommended. IVHQ did so
immediately. Unfortunately, even if the full picture of the outbreak had been known
after confirmation of the second case, because of the lengthy incubation period of the
disease (up to 12 days), moving residents who had already been exposed would not
have prevented them from developing the infection. Simply stated, the majority of the
residents that contracted Legionnaire’s disease in mid-August 2015 were exposed to
the bacteria days before the outbreak was known.

Page 4, Lines 3-4 stating that the administration has not made this a top priority.

This administration has made the response to the 2015 Legionnaires’ disease outbreak
and subsequent remediation and mitigation efforts one of its highest priorities. Upon
notification of the initial cases in 2015, the administration, IDPH, IDVA, and IVHQ
responded immediately, provided proper notifications to staff, residents, and families,
and initiated remediation measures to keep staff and residents safe. These remediation
measures continue, as outlined in this report.

Twelve of the thirteen deaths from Legionnaires’ disease since 2015 occurred in the
initial outbreak in the fall of 2015. Since the initial outbreak, one resident associated with
Legionnaires’ disease has died. This administration takes the care and safety of our
veterans and residents extremely seriously, and has pursued every necessary action to
keep them safe and well-cared for.

II. IVHQ Background


In 1885, the 34th Illinois General Assembly passed legislation to establish a soldiers' and
sailors' home for disabled Illinois veterans of the Mexican and Civil Wars. On June 1,
1886, Governor Richard Oglesby decided on Quincy as the site of the new home and
on October 19, 1886, the Illinois Soldiers' and Sailors' Home was formally dedicated. In
June 1973, the name was formally changed to the "Illinois Veterans’ Home at Quincy."
IVHQ is the largest and oldest veterans’ home of the four in Illinois and one of the larger
and older veterans’ homes in the country. Today, nearly 400 veterans and spouses call
the facility home. Four full-time physicians and more than 330 Registered Nurses,
Licensed Practical Nurses, and Certified Nursing Assistants provide 24-hour a day,
seven-day a week medical and skilled nursing care to residents.

III. Clinical Background On Legionnaires’ Disease


Legionnaires’ disease is caused by a bacterium called Legionella. It is named after a
1976 outbreak, during which some people who went to a Philadelphia convention of the
American Legion suffered from a new type of pneumonia (lung infection) that became
known as Legionnaires’ disease. A milder infection, also caused by Legionella, is called
Pontiac fever. The term “legionellosis” may be used to refer to either Legionnaires’
disease or Pontiac fever.

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A. Reported Cases of Legionnaires’ Disease Are On The Rise

According to CDC, illnesses caused by Legionella are on the rise. About 6,000 cases of
Legionnaires’ disease were reported in the United States in 2015, an increase of nearly
1,000 cases compared to 2014. Since 2000, there has been a 350 percent increase in
the number of reported cases in the United States.

Figure 1: Incidence of Legionnaires’ Disease in the U.S. Increasing Since 2000


(Source: Centers for Disease Control and Prevention https://www.cdc.gov/legionella/qa-media.html)

In Illinois, there were 318 cases reported in 2016—a 100 percent increase since 2010.
Because Legionnaires’ disease is likely under diagnosed, this number may
underestimate the true number of cases each year. It is unknown whether the increase
in reported cases represents a true rise in the actual number of cases, the result of
better diagnostic methods, or increased awareness and testing. The more that health
care providers become familiar with Legionella-related illnesses, the more likely they are
to diagnose Legionnaires’ disease.

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Figure 2: Cases of Legionnaires’ Disease Increasing in Illinois
(Source: IDPH Data)

B. People At Increased Risk

Most healthy people exposed to Legionella do not become ill. People at increased risk
of getting sick are:
• People 50 years or older
• Current or former smokers
• People with a chronic lung disease (like chronic obstructive pulmonary
disease or emphysema)
• People with weak immune systems or who take drugs that weaken the
immune system (like after a transplant operation or chemotherapy)
• People with cancer
• People with underlying illnesses such as diabetes, kidney failure, or liver
failure

These factors are present in many of the residents of IVHQ. In the 2015 outbreak at
IVHQ, the average age of residents with Legionnaires’ disease was 85. Of those
affected, 49 percent were current or former smokers, and 37 percent had chronic lung
disease.

The average age at time of admission is approximately 80 years of age. On


average, a resident resides at IVHQ for 3.5 years. 90 percent of admissions are
due to a decline in health. IVHQ is where veterans and their families choose to come,
because of the community, the facility, and the wonderful care they are provided.

Clusters of individuals with increased susceptibility complicate finding the source of an


outbreak. In a community-wide outbreak, IVHQ residents would be more predisposed
toward illnesses than the general population.

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C. Signs and Symptoms Are Similar to Other Respiratory Diseases

Legionnaires’ disease is a type of pneumonia with symptoms that include:


• Cough
• Shortness of breath
• Fever
• Muscle aches
• Headaches

The signs and symptoms of Legionnaires’ disease are similar to those of other
respiratory diseases, such as community-acquired pneumonia and influenza. This
commonality can delay the diagnosis. Symptoms can appear up to 12 days after being
exposed to the bacteria.

IVHQ patients presented symptoms consistent with all other pneumonias, which
required a clinical discussion over the cause. Clinicians held differing diagnoses of the
causative bacteria. Upon reviewing case chest X-rays, a Blessing Hospital
pulmonologist confirmed signs of congestion, but saw no patterns indicating Legionella
infection. In addition, a Blessing Hospital pathologist raised the possibility of other
causative agents for the residents’ respiratory illness. This highlights the challenge of
diagnosing Legionella infections given their common clinical symptoms. It also
demonstrates why clinicians rely on broad-spectrum antibiotics at the outset to treat all
pneumonias. 3

D. Diagnosis of Legionnaires’ Disease Should Use Rapid Urine Antigen Testing

The diagnosis of Legionnaires’ disease remains a clinical challenge. There is no one


clinical sign or symptom that uniquely distinguishes Legionnaires’ disease from other,
more common causes of pneumonia. The similar symptoms between Legionnaires’
disease and other pneumonias or respiratory infections can delay the determination that
Legionnaires’ disease testing is necessary. Thus, the clinician must have an index of
suspicion for Legionnaires’ disease, and order a specific test to make a confirmed
diagnosis. Nationwide, in most cases testing for Legionnaires is not done when
pneumonia is diagnosed. Despite the diagnostic challenge, most cases of
Legionnaires’ disease will nevertheless be appropriately treated with broad-
spectrum antibiotics at the time their pneumonia is diagnosed. This is because the
same antibiotics that treat Legionnaires’ disease also treat other common causes of
pneumonia.

When testing for Legionnaires is done, results should be returned quickly. As the CDC
noted in its 2015 report, “The lack of on-site rapid Legionella urinary antigen testing with
local clinical care providers delayed the identification of confirmed cases for exposure
assessment. Additionally, there is evidence that limited access to timely testing may

3
Discussed further in Section E: Treatment

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limit case detection, which may have slowed early identification of this outbreak and
limited the validity of baseline Legionnaires’ disease in the community.” 4 According to
longstanding best practices, CDC recommends “local capacity to conduct UAT to
improve turnaround time to under 48 hours.” 5 Thus, CDC recommended, “local
hospitals build capacity for onsite UAT (rapid antigen detection test) and culturing
Legionella from lower respiratory specimens.” 6

Blessing Hospital began working to bring UAT testing online. Rapid onsite testing—as
opposed to testing at distant laboratories—is preferred, both to facilitate appropriate
patient care as well as allow for early identification of outbreaks. Blessing Hospital went
online with its local UAT capacity in early 2018. In addition, IDPH identified a need for
excess statewide UAT capacity in the event of a widespread outbreak. Accordingly, the
IDPH Springfield laboratory went online with UAT capabilities in February 2018.

E. Treatment of Legionnaires’ Disease Is Similar to Other Pneumonias

Legionnaires’ disease can be treated successfully in most cases. When a patient


displays the symptoms of pneumonia, there are two major classes of antibiotics—
fluoroquinolones and macrolides—that can treat most pneumonias, including
Legionnaires’ disease, regardless of the underlying causative bacteria. Based on a
variety of considerations, the clinical provider determines which antibiotic(s) is
appropriate to initiate.

At IVHQ and Blessing Hospital, even while clinicians worked to identify the
bacteria causing residents’ pneumonias, appropriate antibiotic treatment was
provided to patients who accepted it. Thus, there was no delay in treatment for
patients (other than those who may have declined) while test results were coming
back.

F. The Bacteria That Causes Legionnaires’ Disease Is Ubiquitous

Legionella bacteria are found naturally in freshwater environments, like lakes, rivers,
and streams. According to the World Health Organization, “Legionella is ubiquitous in
the natural environment, especially in damp soil and water.” 7 Legionella can become a
health concern when it grows in human-made water systems and spreads through:
• Showers and faucets
• Cooling towers (air-conditioning units for large buildings)

4
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 24.
5
In 2015, Blessing Hospital sent UAT specimens to an outside laboratory, which took 4-5 days to return a
result.
6
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 11.
7
Sakamoto, R. (2015, March 27). Legionnaire’s disease, weather and climate. Retrieved from
http://www.who.int/bulletin/volumes/93/6/14-142299/en/

8
• Hot tubs that aren’t drained after each use
• Decorative fountains and water features
• Hot water tanks and heaters
• Large plumbing systems

G. Legionella Spreads Through Water Systems, Which Makes City-Wide Outbreaks


Possible

After Legionella grows and multiplies in a building water system, contaminated water
then has to spread in droplets small enough for people to inhale. People most
commonly acquire Legionnaires’ disease when they breathe in small droplets of water in
the air that contain the bacteria.

In general, people do not spread Legionnaires’ disease (or Pontiac fever) to other
people. This fact adds to the complexities of an investigation. Determining the source is
difficult when cases have common, community-level exposures, such as being within
the radius of a municipal cooling tower or having visited the same locations in a small
town. This was seen with some of the early cases in 2015. In fact, there were two
cases in August 2015 from Adams County that had no contact with IVHQ. In addition,
the early cases at IVHQ had several exposures outside of the facility. The reporting of
community cases along with IVHQ residents who had travelled across the city of Quincy
complicated identification of the source of the outbreak. Investigators from Adams
County and IDPH interviewed each patient, developed a comprehensive travel history
for the two weeks preceding the onset of symptoms, and then looked across those
various findings for common locations that all the cases visited. Thus, public health’s
outbreak response simultaneously provided the facility guidance on mitigation strategies
while investigating the possibility of a community-level source.

IV. Baseline Epidemiology At IVHQ


In assessing any outbreak, comparisons to the baseline level of disease are the first
step toward understanding the situation. Prior to 2015, IVHQ residents experienced
seasonal peaks (although not above the national average) in pneumonia rates. 8 As
displayed in Figure 3, there were notable pneumonia spikes in 2006 and 2008. There is
no evidence that testing for Legionnaires’ disease was done during the pneumonia
spikes in 2006 or 2008. Because the symptoms of different pneumonias are largely
identical, regardless of cause, and Legionnaires’ disease is under diagnosed, there is a
possibility that some prior “pneumonia” cases were actually Legionnaires’ disease
cases. And because providers in the past may not have tested specifically for
Legionnaires’ disease, arriving at a baseline rate of disease is challenging. Once a
patient is treated with antibiotics, symptoms typically diminish, negating the need for
further testing. This resolution of clinical symptoms and lack of historical testing further
complicates efforts to determine the baseline rate of Legionnaires’ disease at IVHQ.

8
According to IDPH data, there were two cases of Legionnaires’ disease Adams County from 2010-2014.

9
Percentage of Residents with Pneumonia at IVHQ 2006-2017
14

12

10

0
Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.

2006 2007 2008 2009 2010 2011


2012 2013 2014 2015 2016 2017

Figure 3: Pneumonia rates among IVHQ residents between 2006-2011. Seasonal fluctuations are common and
notable spikes in illness can be seen in 2006 and 2008, as well as 2015. IVHQ reported below-average rates of
pneumonia (which may have included undiagnosed Legionnaires’ disease cases) prior to 2015.
(Source: IDPH Data)

V. The Response To The Outbreak Followed CDC’s Best


Practices And Reduced The Spread Of Disease
The goal of outbreak response is to stop a sharp rise in case counts and protect public
health. On August 21, 2015, IDPH was notified of a second confirmed case of
Legionnaires’ disease associated with IVHQ. IDPH immediately notified IVHQ and, in
conjunction with ACHD, provided guidance on mitigation steps that would reduce the
risk of further disease transmission to residents who had not already been exposed to
Legionella bacteria. 9 In doing so, IDPH followed a CDC-approved outbreak response
plan that focuses on three areas: epidemiological assessment, environmental health
testing, and clinical/infection control strategies. IVHQ implemented IDPH and CDC’s
guidance. The quick, coordinated, and comprehensive response to this tragic outbreak
reduced the spread of disease and stopped the rise in cases.

9
Unfortunately, there are no known scientifically proven measures that could have protected residents
who had been exposed to Legionella bacteria in the preceding twelve days.

10
A. The Immediate Response Put Into Place Measures That Protected Patients From
Further Risk

In any outbreak response, there are three fundamental questions that must be
addressed:
• Who is at risk?
• From where are they getting infected?
• What can at-risk individuals do to prevent further cases?

These three questions frame the pillars for a public health agency’s role in an outbreak
situation:
• Epidemiological Assessment – identifying similarities and common sources of
exposure to determine who is at risk
• Environmental Health Testing – determining the source of the outbreak to
determine from where affected patients are getting infected
• Clinical and Infection Control – providing recommendations to increase
screenings and implement controls to prevent further cases in at-risk individuals

In suspected healthcare facility outbreaks, the first priority of a public health agency is to
provide recommendations to the facility, since it is the facility that can put into place
measures to keep residents safe. Within 27 minutes of receiving confirmation of the
second case of Legionnaires’ disease at IVHQ, IDPH staff coordinated a conference call
with IVHQ and IDVA staff and representatives from ACHD to discuss the two cases and
provide recommendations. These recommendations addressed any immediate risk at
IVHQ while IDPH and ACHD staff continued their investigation. IDPH recommended
that IVHQ:
• Turn off the outdoor fountains
• Keep windows closed
• Use bathing facilities other than the one the two cases used
• Ensure appropriate disinfectant in the cooling tower and water chiller units
• Provide cooling tower maintenance log to IDPH EH specialists
• Conduct prospective surveillance for other respiratory illnesses
• Begin conducting vital screenings at four-hour intervals for skilled nursing care
residents

IDVA accordingly took the following actions on August 21st, 2015:


• Turned off all fountains on grounds
• Notified staff to close all windows and keep them closed
• Removed aerators from sink faucets in residents’ rooms
• Checked Whirlpool tubs for bubbling features – none detected
• Suspended the use of tubs in the West/Elmore II bathing room
• Suspended the use of ice machines in the Elmore building
• Inspected the disinfectant levels in the cooling tower and water chiller units
• Began checking for signs and symptoms of respiratory illness and checked vitals
of every skilled care resident every four hours beginning August 22, 2015

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B. The Epidemiological Response Is Designed To Find Common Sources Of Exposure
Among Cases

The epidemiological response is designed to identify similarities among cases and find
common sources of exposure. Epidemiologists begin by thoroughly investigating the
case(s) to determine all potential exposures during the case’s incubation period. This
includes identifying everywhere an individual visited, worshipped, ate, drank, and
socialized. Most people would find it difficult to chronicle the last 24 hours of their lives
with the necessary specificity to track exposure, let alone the last two weeks. Given that
elderly individuals may have limited recall, the disease detectives faced significant
challenges.

These findings guide the environmental assessment, as they determine possible


sources and areas for testing, such as where a person showered. Epidemiologists also
conduct retrospective surveillance of the past several months of medical data to
determine if there were prior individuals who became ill that were not identified as being
part of the outbreak. Simultaneously, scientists begin intensive prospective surveillance
for additional health care associated infections.

Given the lengthy incubation period of Legionella, it is difficult to collect case histories
and isolate a source of infection. 10 The population that most often demonstrates
symptoms has underlying health issues, particularly respiratory health issues, like many
of the residents who became ill at IVHQ.

At the same time cases began to be reported at IVHQ, Adams County began
seeing cases in the broader community. 11 Because of these community cases in
Quincy during this time, IDPH could not determine immediately whether the
source of the outbreak was at IVHQ or elsewhere in the community. The multiple
exposure points and wide geographical area with cases reported meant that
investigators had to consider several different sources. Over the weekend following the
second confirmed case, IDPH worked to determine case histories for the affected
patients and conducted environmental testing to try to identify the source(s) of infection.

After the investigation, the community cases were determined to be point source cases
unrelated to those cases at IVHQ. At this time, IDPH determined the outbreak was
centered around IVHQ. Thus, there was not thought to be a generalized risk to the
public. Once this determination was made efforts could be solely directed at IVHQ.

10
Case history collection entails asking a suspect case to list every location they have visited in the two
weeks prior to symptom onset. This is obviously very challenging to recall, especially for ill individuals.
Once travel histories for all cases have been assembled, epidemiologists must review all the locations to
look for common sites, which could suggest the source of infection in an outbreak.
11
A total of five community cases were eventually reported.

12
Epidemiological response is also focused on determining precisely when an outbreak
began, peaked, and subsided. According to CDC, “the Legionnaires’ disease outbreak
curve indicated a likely point-source outbreak with a peak on August 23-24, which had
largely resolved by August 31.” 12 This means that the remediation efforts recommended
by IDPH and implemented by IDVA within the first two weeks significantly reduced
further infections, as demonstrated by the CDC’s chart, shown in Figure 4.

Figure 4: Epi-curve of confirmed Legionnaires’ disease Pontiac fever cases by date of symptom onset with select dates of
interventions shown – Illinois Veterans Home, Quincy, Illinois – 2015
* Community cases are confirmed Legionnaires’ disease case-patients with no exposure to the IVH facility or surrounding area.
(Source: CDC Trip Report http://dph.illinois.gov/sites/default/files/publications/cdc-trip-reportquincyil12.31.15.pdf)

C. The Environmental Health Response Is Focused On Finding The Source Of An


Outbreak

The environmental health response is focused on determining the source of the


outbreak. In Legionella situations, environmental engineers conduct an investigation by

12
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 11.

13
collecting water samples from potential sources of aerosolized water. If a source of
infection is identified, engineers provide guidance on properly decontaminating the
source. Environmental health specialists also provide guidance on implementing water
restrictions, as was done with IVHQ. Further, engineers continue to collect samples as
interventions are put into place to determine whether bacterial levels are falling.

Legionella investigations in health care facilities are challenging, especially one with a
large, aging, and complex plumbing system such as that at IVHQ. Starting on August
21, 2015, IDPH’s Division of Environmental Health (EH) and ACHD completed a series
of environmental assessments to identify Legionella exposure sites and to implement
initial risk mitigation strategies. 13 These tasks entailed a review of water system
operation and maintenance records, sampling protocols and results, water emergency
plans, and discussion with staff about training and experience with Legionella
prevention and control. Given that IVHQ is a multi-building campus, the environmental
health assessment was especially complex. Specific areas assessed included resident
care areas, resident bathing areas, facility common areas, decorative fountains, and the
hot and cold-water infrastructure.

Evaluating, testing, and treating all potential sources requires time and coordination.
Given the complexities of Legionella investigations, IDPH worked with CDC and invited
CDC representatives to visit IVHQ to provide technical assistance and conduct
additional testing. Having recently assisted New York City on its Legionella response,
CDC initially suspected the IVHQ cooling tower as the primary source of the outbreak.
However, IDPH staff felt that the hot water tanks might have also contributed to disease
spread. Through the EH investigation, it was determined that the high levels of bromine,
a disinfecting substance, found in the cooling towers would not support Legionella
growth. Therefore, the cooling towers were likely not the source. IDPH began campus-
wide environmental testing to search for other potential sources—the top candidate
being the potable water system. Test results, which can take up to two weeks for final
confirmation, would help guide analysis and determination of a potential source.

Given the case distribution throughout the campus’ many buildings, with some residents
visiting a number of the buildings, as well as traveling off campus, all of these locations
presented a potential source of the infection. The abundance of exposure points and
limited case history data prompted the EH team to assess all the likely sources of
Legionella across the City of Quincy, not just those at IVHQ. The following direction was
given by IDPH EH Engineering:
• Immediately increase cooling tower free bromine level to 10ppm, logging every
four hours
• Isolate tank #2 from the hot water supply in the power house, empty tank #2 for
swabbing 8/27/15
• Desist using tap water for any resident care or service
• Order bottled or packaged water for potable uses

13
As noted in the timeline, CDC was consulted and briefed at each step starting on August 23, 2015

14
• Discontinue any potable water use involving point-of-use fixtures where aerosols
are likely

IDVA accordingly took the following actions:


• Shut the cooling towers down to clean and disinfect them – increasing bromine
levels to 10ppm, but returned them to operation to prevent building evacuation on
August 28, 2015. (These towers provide air conditioning to the buildings and
IVHQ is required to maintain air conditioning in residential buildings).
• IVHQ began keeping a daily log of tower disinfection on August 26, 2015 and
that protocol continues in cooling season to this day.
• IVHQ isolated tank #2 from the hot water supply and emptied the tank for
swabbing on August 27, 2015
• The cooling tower was cleaned and disinfected again on September 8, 2015 and
was shut down completely on September 30, 2015, for the season.
• Ordered a 500-ton portable cooling tower on August 26, 2015, for delivery in the
next 48 hours
• Ordered bottled and packaged water for distribution site-wide on August 26, 2015
• Implemented a site-wide ban on bathing with domestic water (alternate bathing
methods implemented) and ceased using tap water for resident care or service
on August 26, 2015
• Implemented emergency purchasing action to onboard a consulting firm to assist
with mitigation (Phigenics) on August 26, 2015
• Emptied the main entrance fountain on August 26, 2015

D. The Clinical And Infection Control Response Prevents Disease Transmission

The clinical/infection control aspect of an outbreak response provides recommendations


to facilities that can ultimately reduce disease transmission. These recommendations
include increased patient screenings as well as additional controls against infection,
where applicable. In a Legionella situation, the clinical recommendations focused on
these areas:
• Increase vital sign checks on all patients to actively search for potential
Legionella infections (called “active disease surveillance”)
• Maintain a high index of suspicion for the diagnosis of healthcare associated
Legionnaires’ disease, especially among high-risk patients
• Perform laboratory diagnostic testing (both culture and urine antigen)
• Submit isolates to CDC for speciation 14

14
Tablan, O.C., Anderson, L.J., Besser, R., Bridges, C., and Hajjeh, R. (2003). Guidelines for Preventing
Health-Care--Associated Pneumonia, 2003. Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

15
CDC noted that, prior to the outbreak, “IVH ha[d] a well-established clinical infection
surveillance and prevention program in place.” 15 Per IDPH guidance, IVHQ increased
the frequency of vital sign checks to every four hours for skilled care residents on
August 22nd, in order to find pneumonia as early as possible. Further, CDC noted, “Per
established IVH protocol, any resident developing symptoms consistent with a lower
respiratory infection had a chest X-ray performed immediately for pneumonia diagnosis.
This standard protocol was expanded to include urine and sputum sample collection for
Legionella testing throughout the outbreak period. Residents diagnosed with pneumonia
were transferred to Blessing Hospital for treatment unless they refused or treatment was
contraindicated due to a standing ‘comfort care only’ order.” 16

Patients who agreed to treatment did not wait for a confirmed diagnosis. Rather,
according to CDC, “IVH chose to empirically treat these residents in an effort to
ensure patient safety.” 17 This means that patients were given an antibiotic that
would appropriately treat their pneumonia, regardless of the bacteria causing it.

VI. IVHQ Residents And Employees Were Notified About


Legionnaires’ Disease
A. Residents Were Notified During Enhanced Vital Sign Screenings

Upon notifying and educating the IVHQ nursing staff on Legionella, IVHQ staff
increased clinical protocols to include taking vital signs every four hours and monitoring
residents in intermediate and skilled care for signs and symptoms of pneumonia. 18
During these clinical checks, residents were informed that a respiratory infection was
affecting residents across the campus. IVHQ’s protocol of immediately notifying every
resident’s POA whenever his or her health status changes continued during this time
and continues today.

B. Employee Notification Included Education About Legionnaires’ Disease

In 2015, the recommendations and guidance IDVA gave to the IVHQ staff primarily
included education regarding Legionnaires’ disease, how to provide appropriate clinical
care to affected residents, and how to screen for potential new cases. This specific

15
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 10.
16
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 11.
17
Centers for Disease Control and Prevention. (2015). “Epi-Aid 2015-037 Trip Report: ‘Undetermined
source of an healthcare-associated outbreak of Legionnaire’s disease — Illinois, 2015.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 10-11.
18
Beginning on August 28, 2015, vital signs were also taken every four hours for residents of the
independent living facilities.

16
education was important because, as CDC has noted, IVHQ already had a well-
established clinical infection surveillance and prevention program in place.

IVHQ leadership took immediate action to inform the staff of two positive cases of
Legionnaires’ disease after being informed of those cases by IDPH and ACHD on
August 21, 2015. On August 22, the IVHQ Infection Control Coordinator (ICC) spoke
directly to the entire nursing staff in the building with the positive cases and issued an
email to all direct care licensed nursing staff notifying them of the results. Additionally,
the ICC provided a short educational training on Legionnaires’ disease for licensed
direct care staff via email. CNAs, who do not have state-issued email accounts, were
informed by their supervisors at the beginning of each shift. On August 25, an email was
sent to IVHQ employees, with a read-receipt notification indicating whether the email
was opened and read, regarding the discovery of Legionella and providing information
about Legionnaires’ disease.

On August 26, 2015, the IVHQ Administrator conducted two mandatory all-staff
meetings. These meetings provided the entire staff with training and education on
Legionnaires’ disease. During the meetings, IVHQ leadership distributed educational
information from CDC about Legionnaires’ disease. These educational handouts were
also emailed to IVHQ employees and posted at the nurses’ station. All employees had
to sign in at the all-staff Town Hall style meetings where IVHQ leadership provided an
opportunity for staff to share concerns, ask questions, and clarify further actions. In
addition, all emails were sent with a read-receipt notification indicating whether the
email was opened and read. Staff members without email were given educational
materials and minutes from the Town Hall style meetings.

VII. Remediation Efforts Improved Water Quality And


Significantly Reduced Legionnaires’ Disease Cases
IDVA and IDPH remain focused on eliminating the risks of Legionnaires’ disease for the
veterans who live at IVHQ and staff who work there. We continue to engage fully with
experts from CDC to implement and exceed its recommendations and to ensure that
remediation efforts adhere to best practices.

Since 2015, IDVA has developed and implemented a formal water management plan,
including a Legionella-specific prevention plan. At the time they were enacted, neither
was required by IDPH nor the CDC. The CDC reported in 2016, “[IVHQ’s] written
water management program aligned with the best practices identified in CDC’s
water management toolkit. Control measures, control limits, and control points, were
routinely identified and corrective actions consistently taken. The program included
contingency responses, verification and validation procedures, routine program review,
and communication procedures.” 19
19
Centers for Disease Control and Prevention. (2017). “Epi-Aid 2016-045 Trip Report: ‘Healthcare-
associated outbreak of Legionnaires’ disease among veterans—Quincy, Illinois, 2016.’” Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis,14.

17
Since the water management plan has been implemented, CDC found that the
“significant remediation efforts undertaken by [IVHQ] have substantially reduced
the presence of Legionella in the potable water system. 20 Based on observations
during the Epi-Aid investigation, the water management program was fully implemented,
followed, and continuously reviewed by the water management team to optimize the
water systems.” 21

Figure 5: Fall in Legionella bacteria levels at IVHQ following initial 2015 remediation efforts
(Source: Phigenics Test Results)

As CDC stated in its 2018 report, “Recognizing the persistence of this strain [of
Legionella] within IVHQ and the probability that some level of Legionella
colonization may continue, our recommendations are focused on minimizing the
risk of exposure among residents, staff and visitors. While adoption of these
recommendations should further reduce risk, the possibility of future cases of
disease associated with IVHQ cannot be eliminated.” 22

20
See Figure 5.
21
Centers for Disease Control and Prevention. (2017). “Epi-Aid 2016-045 Trip Report: ‘Healthcare-
associated outbreak of Legionnaires’ disease among veterans—Quincy, Illinois, 2016.’” Retrieved
from,15.
22
Centers for Disease Control and Prevention. (2018). “Illinois Veterans Home Legionella Investigation —
Quincy, Illinois, 2017.” Retrieved from http://dph.illinois.gov/topics-services/diseases-and-
conditions/diseases-a-z-list/legionellosis, 11.

18
A. Remediation Steps Were Designed To Reduce Bacterial Levels And Risk of Disease

Beginning in August 2015, IDVA and IDPH enlisted the expertise of the CDC, which
provided recommendations designed to reduce levels of Legionella bacteria quickly.
The recommendations, which IDVA implemented, included:
• Taking the water tower out of service
• Building a new multimillion-dollar water treatment plant that constantly monitors
and chemically treats the water
• Taking the cooling towers offline, disinfecting them, and monitoring them with
proper chemical control and treatment
• Ensuring every building’s plumbing entrance was equipped with a backflow
prevention mechanism
• Installing more than 40 water heaters in 37 buildings, including residential
buildings
• Heating water at the source to 165 degrees Fahrenheit to kill the Legionella
bacteria, where possible
• Installing water mixing valves at every faucet to cool water
• Installing filters on every shower and sprayer
• Replacing therapy tubs with soaking tubs
• Implementing a state of the art water management program, which includes daily
flushing, testing, and treatment of the water
• Installing Pall filters on every faucet on the grounds. More than 700 Pall filters
have recently been fitted. These filters block the Legionella bacteria, preventing
anyone near that faucet from exposure
• Flushing the entire system twice a day so there is no stagnant water in the pipes

B. Potable Water Improvements Have Reduced The Risk of Legionnaires’ Disease

After a thorough review of IVHQ’s potable water system, a team comprising IDPH,
IVHQ engineering and administrative staff, Quincy’s municipal water works, private
Legionella mitigation contractors, and CDC developed a potable water remediation
strategy. The goal was to increase the amount of chlorine in the water to reduce the risk
of Legionella across the entire system. Post-remediation samples taken at 15 select
locations throughout IVHQ on September 11, 2015 and September 24, 2015,
showed no Legionella growth.

Following the recommendations from the CDC, IDVA made numerous improvements to
the potable water system on the IHVQ campus. These improvements include:
• Removal of large sections of unused piping and the water tower from the water
distribution system
• Consolidation of municipal water mains to one inlet delivering all potable water to
the campus
• Installation of dedicated recirculating hot water systems in each residential
building and Smith Hall kitchen to significantly increase hot water temperatures
• Installation of automatic flushing stations for on-campus water mains

19
• Construction of an on-campus chemical treatment plant for injection of secondary
disinfectant (12.5 percent sodium hypochlorite and chlorine dioxide) into the
potable water under guidance of water and chemical treatment service provider
• Installation of thermostatic mixing valves at sink faucet and shower fixtures, as
well as 0.2 micron point-of-use filters for the removal of Legionella on all
showerheads and hand-held sprayers on therapy tubs (i.e., Pall filters)
• Daily flushing at all terminal fixtures per the water management program

C. Improvements To The Cooling Towers Reduced The Risk Of Aerosolized Bacteria

IDVA has made significant improvements to the cooling towers’ operation and
maintenance. These include automating the biocide delivery system and chemical
parameter monitoring, under the guidance of a water and chemical treatment contractor.

D. Significant Infrastructure Improvements To Modernize The Water System

From an infrastructure perspective, IDVA invested $6.4 million in building a water


treatment facility. All necessary funds originated under grants from the federal Clean
Water Act provided by the Illinois Environmental Protection Agency. In addition to
building a brand-new water treatment facility, IVHQ also implemented a robust water
management plan following the guidance and recommendations of IDPH and CDC.
Water quality parameters are measured and adjusted every day.

Most recommendations for water remediation suggest either thermally heating


the water, chemically treating the water, or filtering the water. IVHQ pursues all
three strategies simultaneously. IVHQ thermally heats the water to 165 degrees
Fahrenheit to kill bacteria in the water. Chemical treatment of the water with sodium
hypochlorite and chlorine dioxide prevents bacteria growth. IVHQ also initially installed
Pall filters, which are specifically designed to block Legionella bacteria, on every single
shower, tub, and sprayer across the campus. More recently, IVHQ installed Pall filters
on every sink faucet across campus. In its 2016 visit, the CDC “team further observed
real-time application of contingency responses to potential exposure risks at facility.” 23

All of the abovementioned actions taken to mitigate the risk of Legionnaires’ disease
and protect residents and staff have reduced cases at IVHQ. As the CDC notes,
“Efforts by IDPH and IVHQ to control Legionella resulted in substantially fewer
Legionnaires’ disease cases in 2016 (N=5) and 2017(N=6) compared to 2015
(N=46).” 24

In July 2016, the Capital Development Board (CDB) commissioned BRiC to research
methods to reduce the likelihood to Legionella’s further recurrence. Approximately one
23
Centers for Disease Control and Prevention. (2017). “Epi-Aid 2016-045 Trip Report: ‘Healthcare-
associated outbreak of Legionnaires’ disease among veterans—Quincy, Illinois, 2016.’”Retrieved from
http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/legionellosis, 14.
24
Centers for Disease Control and Prevention. (2018). “Illinois Veterans Home Legionella Investigation —
Quincy, Illinois, 2017.” Retrieved from http://dph.illinois.gov/topics-services/diseases-and-
conditions/diseases-a-z-list/legionellosis, 11.

20
month after the completion of IVHQ’s water treatment plant, BRiC produced the “IVHQ
Legionella Response Plan 2016, Proposed Project Elements” report, dated August 5,
2016. The report’s scope encompassed 12 of the 48 buildings on IVHQ’s campus.
While comprehensive, the BRiC report provided several options that could be
considered by IVHQ to further remediate the water. The BRiC recommendations did not
take into account the $6.4 million water treatment facility that had just been completed
at IVHQ. When the 2016 BRiC report was released, the IVHQ team was testing the
efficacy of the new water treatment facility. In doing so, IDVA was following the CDC
recommendations and guidance as the nation’s leading experts on Legionella bacteria.

In January of 2018, CDB asked BRiC to update its August 2016 report to focus on
replacing all site and building piping. The 2018 report’s scope was more expansive and
included 32 buildings, which accounts in large part for the price difference from the 2016
report. Put differently, the two proposals were not estimates for identical projects.

VIII. Next Steps


The State of Illinois remains committed to improving the safety of residents and staff at
IVHQ. Every option is on the table and being studied. As detailed in this report, many
interventions have already been completed, such as installing new faucets and Pall
filters across the entire campus – approximately 700 points of use campus wide. As a
result, there have been no post-filter positive water tests for Legionella since completion
of the latest remediation.

A. Ongoing Actions

In February 2018, four cases of Legionnaires’ disease were diagnosed. These cases
were detected in part because of the active disease surveillance system in place since
2015. IDPH and CDC returned to IVHQ to provide technical assistance to IDVA. Since
the cases confirmed in February, IVHQ has:
• Installed more than 700 new faucets with Pall micron filters across the entire
campus. These filters block bacteria, including Legionella, and have been proven
to be 99.9 percent effective
o Filters have already been in use on showerheads since early 2016, per
CDC recommendations
o Water tests after the filters have shown zero presence of Legionella since
the installation was completed on March 3, 2018
o The filters will be replaced every 30 days, or sooner as needed
• Installed Bolus systems in residential buildings and will install these systems at
each building campus wide. These systems monitor disinfection levels in real
time and add an additional layer of chemical treatment, if needed, when the
monitors detect low chemical residual
• Begun re-sanitizing the entire HVAC system on campus

21
• Continued flushing procedures and water testing before and after the filters to
show the effectiveness at each point-of-use

IDPH continues its weekly calls with the IVHQ and IDVA facilities staff to monitor cases
for any patients with respiratory symptoms. IDPH also works with CDC and water
management consultants to review ongoing environmental testing results and advise on
next steps. The State continues to improve the IVHQ water management plan, and
explore additional steps that will ensure the safety of the IVHQ water system.
The IDPH laboratory will maintain its advanced UAT capacity, while working with
hospitals to ensure accuracy of their testing and responsiveness. Finally, IDPH will
provide advice, as appropriate, on the health implications of any future plans involving
resident relocation.

B. Short-Term Actions

The State is also working to procure a vacant nursing home a few blocks from IVHQ,
renovate it, and prepare it for occupancy while renovations and new construction takes
place on the Quincy campus. In addition, experts are studying further options to
determine the best courses of action for water remediation. IDVA established a Water
Management Task Force to review and assess an evolved plan for remediation of water
at IVHQ. The remediation plan might include new plumbing, a new water source, new
flushing protocols, new technologies for testing—or all of the above. The goal is to
determine the most effective and cost-efficient way to ensure the continued provision of
safe water for residents and staff.

The State is also exploring the use of modular buildings on the grounds that could serve
as temporary residence halls. The new facilities will ensure IDVA has a temporary
housing solution in the event residents need to be moved to further protect them from
Legionella. There is no immediate plan to transfer residents.

These options will minimize risks inherent in moving elderly residents (so called
“transfer trauma”), allow residents and staff to remain in the Quincy community,
maintain their connection to fellow veterans, and provide a continuity of the high-quality
care provided at IVHQ.

C. Long-Term Actions

As part of the State's long-term plan, CDB is searching for a firm to provide a master
plan for a new, state-of-the-art facility that will meet the needs of today's veterans.
Changing demographics of the veterans who will be served by the IDVA Veterans
Homes requires IDVA to adapt service delivery models. These changes are due to
differences in life experiences between generations, clinical needs, and the service
expectations of veterans and their families. While most of these changes will be internal
to IDVA processes, some of the needed changes will require significant infrastructure
investment. This project will be informed by the Illinois Veterans Homes Capital Needs
Assessment Report, which will be presented to the General Assembly by May 1, 2018.

22
A request for qualifications for a Master Planner is posted on the procurement section of
CDB’s website, and submittals are under review.

Governor Rauner has also tasked IDVA to establish an Infrastructure Investment Task
Force to assess the plans for the design, build, and construction requirements for
projects at IVHQ—and the other Homes, as needed. This Task Force will have the
opportunity to think broadly about what the future of care will look like for our Illinois
veterans. The Infrastructure Investment Task Force will need to take into account the
needs that veterans will have in the next 5, 10, 20 years—and beyond. A final plan will
be presented to the Illinois General Assembly with a request for appropriations to
implement.

The State will continue to work with the Illinois General Assembly to expedite the
procurement process and reduce red tape. Proposals will be submitted to the legislature
when the Illinois General Assembly reconvenes in April 2018. The State also looks
forward to partnering with Illinois’ U.S. Congressional delegation to secure critical
funding for this and other projects. The State will soon submit its initial application for a
grant that covers up to 65 percent of building a new facility to the U.S. Department of
Veterans Affairs. If these infrastructure changes occur, the projected capacity of the
Veterans’ Homes, by service, would greatly improve and residents will be offered
additional amenities and more tailored care delivery.

IX. Timeline of Events


July 24, 2015 (Friday)
• First case begins showing symptoms (no diagnosis made)

July 29, 2015 (Wednesday)


• Specimen from first case collected

August 4, 2015 (Tuesday)


• Adams County Health Department (ACHD) receives outside lab results for first
case

August 5, 2015 (Wednesday)


• ACHD investigation begins

August 6, 2015 (Thursday)


• ACHD notifies IVHQ of confirmed case and obtains further details of the
individual (symptoms, exposures, etc.)

August 7, 2015 to August 20, 2015


• ACHD continues investigation – IDPH notified and consulted

August 21, 2015 (Friday)

23
• Conference call among IDPH, IDVA, ACHD, and IVHQ about second confirmed
Legionnaires’ disease case. IDPH requests additional information regarding:
o Clinical and epidemiological information regarding case (symptoms,
exposures, travel, etc.)
o Cooling tower operations and maintenance
o City of Quincy test of facility water
o Cooling tower maintenance logs
• Initial recommendations from IDPH:
o Turn off outdoor fountains
o Keep windows closed
o Use bathing facilities other than the one the two cases used
o Ensure appropriate disinfectant in the cooling tower and water chiller units
o Conduct prospective surveillance for other respiratory illnesses
o Begin conducting vital sign screenings for skilled nursing care residents at
four-hour intervals (temperature, heart rate, etc.)
• IDVA initial steps taken to implement IDPH recommendations:
o Turned off all fountains on grounds
o Notified staff to close all windows and keep them closed
o Removed aerators from sink faucets in residents’ rooms
o Checked Whirlpool tubs for bubbling features – none detected
o Suspended the use of tubs in the West/Elmore II bathing room
o Suspended the use of ice machines in the Elmore building
o Inspected the disinfectant levels in the cooling tower and water chiller
units
o Began checking for signs and symptoms of respiratory illness and
checked vitals of every skilled care resident every 4 hours beginning
August 22, 2015
• IDPH Chief Medical Officer describes situation as “possible outbreak”
Epidemiological link between the two cases not established at this time

August 22, 2015 (Saturday)


• IDPH requests further information about the IVHQ cooling towers
• IVHQ sends email to all nurses regarding the Legionnaires’ disease
cases. Email includes educational material about the disease.
• IVHQ supervisors brief all nursing staff at the beginning of their shift about
Legionella bacteria and Legionnaire’s disease
• IVHQ’s infectious disease nurse meets with nursing and housekeeping staff,
offering more information and answering questions about the disease
• IVHQ Infection Control Coordinator (ICC) provided an in-person education
session to all nursing staff in the Elmore building and followed up the session
with an email to all nurses campus wide
• All IVHQ direct care staff began conducting vital signs every four hours on all
skilled-care residents

August 23, 2015 (Sunday)

24
• IDPH begins multiple, daily communications with CDC Legionella team (clinical,
environmental health, and epidemiological)
• IDPH communicates with Blessing Hospital about IVHQ residents at the hospital
and conducting interviews of cases to collect epidemiological information
• IDPH requests sputum collection from anyone at IVHQ suspected to have
Legionella
• IDPH adds recommendations to its initial mitigation plan, including:
o Continue surveillance/referral for medical care
o Culture of sputum from all patients so that clinical and environmental
isolates can be compared via Pulse Field Gel Electrophoresis (DNA
subtyping)
o Obtain more exposure information on cases
o Conduct inspection of potential sources of infection
o Perform environmental testing
• In response to the additional IDPH recommendations, IVHQ took the following
actions:
o Continued every four-hour vitals checks
o Began attempting to take sputum samples from residents exhibiting signs
and symptoms. This proved to be very difficult because respiratory illness
(coupled with COPD and other respiratory issues) can make it impossible
for a subject to provide a sputum sample
o Maintained detailed charting protocols
o Informed powers of attorney (POAs) of any health status changes
immediately
o Cooperated with the IDPH and ACHD teams to provide information for the
investigations to identify potential sources of infection

August 24, 2015 (Monday)


• IDPH continues multiple, daily communications with CDC
• IDPH & IDVA begin daily updates to Governor’s Office
• IDPH team on site at IVHQ. Three staff from environmental health and two from
infectious disease
• Teams collect resident location and histories and enter information into Illinois
National Electronic Disease Surveillance System (INEDSS)
• IDVA, IVHQ, IDPH, ACHD phone calls to review lists of suspect cases. Purpose
is to compile clinical and laboratory information to determine if cases meet CDC
case definition for Legionnaires’ disease or Pontiac fever
• IDPH, IDVA, IVHQ, ACHD, and Blessing Hospital discuss suspect cases
• Review and inspection of HVAC, on-site mechanical systems, plumbing system,
and two outdoor water fountains
• IDPH collects water samples and swab samples from fountains, cooling tower,
bathing tub, and showerheads
• IDPH provides further mitigation plan recommendations:
o No tub baths, not even use of tub with hand-held shower piece only
o Sponge baths would be safest at this time
o Replace shower heads with filter-type shower head

25
o Empty all fountains
o Provide training for facility staff on water systems testing procedures
o Document all testing and temperature monitoring in water systems
o Document disinfection of bath tubs
• Implement hot water restrictions
• In response to the additional IDPH recommendations, IVHQ took the following
actions:
o Ceased all tub baths and showers
o Ordered filters for shower heads
o Conducted sponge baths using disposable wet towels
o Emptied the fountains
o Began testing, monitoring, and documenting results for all water systems

August 25, 2015 (Tuesday)


• IDPH continues multiple, daily communications with CDC
• IVHQ conducts an all-staff nursing education session on Legionnaires Disease
• IVHQ sends email to employees regarding discovery of Legionella bacteria and
information about Legionnaires’ disease
• One of the initial two cases noted to also be Mycoplasma positive, meaning that
patient could have another form of pneumonia, not Legionnaires’ disease
• IDPH disease surveillance epidemiologists look for increase in respiratory illness
cases across Adams County
• IDPH Laboratory ships clinical specimens to CDC for antimicrobial testing
• Discussion of Blessing Hospital’s surge capacity
• IDPH recommends that IVHQ not admit new residents until disease testing and
environmental surveillance are complete
• Track people admitted to hospital for respiratory illness

August 26, 2015 (Wednesday)


• IDPH continues multiple, daily communications with CDC (including discussion of
point-source (cooling tower or potable hot water supply))
• IVHQ holds two Town Hall-style meetings that included all staff members
• During the meetings, IVHQ distributes educational handouts from the CDC
• The educational handouts were also emailed to all IVHQ employees
• All employees had to sign in at the Town Hall-style meetings
• All emails were sent with a designation returning to the administration that
the email was opened and read
• Staff members without state email addresses were updated by their
supervisor at the beginning of their shift
• IDPH issues recommendations for clinical sampling and continued active disease
surveillance
• All sink aerators removed and hot-water restrictions continued to eliminate
shower and tub use
• Blessing Hospital pathologist inquires about Legionella diagnoses
• Draft news release is circulated
• IVHQ is sending everyone with fever and cough to the hospital

26
• New information regarding the hot water distribution system collected
• IDPH performs targeted sampling of the domestic hot water system. Additional
water samples and swabs collected. Polymerase Chain Reaction (PCR) and
culture analysis were ordered for all samples
• Issuance of draft guidance on disinfection of cooling tower
• The following direction was given by IDPH EH:
• Immediately increase cooling tower free bromine level to 10ppm logging
every four hours
• Isolate tank #2 from the hot water supply in the power house, empty tank
#2 for swabbing 8/27/15
• Desist using tap water for any resident care or service, order bottled or
packaged water for potable uses
• Discontinue any potable water use involving point of use fixtures where
aerosols are likely
• IDVA accordingly took the following actions:
• Shut the cooling towers down to clean and disinfect them – increasing
bromine levels to 10ppm, then returned them to operation to prevent
building evacuation on August 28, 2015. (These towers provide air
conditioning to the buildings and IVHQ is required to maintain air
conditioning in residential buildings).
• IVHQ began keeping a daily log of tower disinfection on August 26, 2015
and that protocol continues in cooling season to this day.
• The cooling tower was cleaned and disinfected again on September 8,
2015 and was shut down completely on September 30, 2015, for the
season.
• Ordered a 500-ton portable cooling tower on August 26, 2015, for delivery
in the next 48 hours
• Ordered bottled and packaged water for distribution site-wide
• Implemented a site-wide ban on bathing with domestic water (alternate
bathing methods implemented) and ceased using tap water for resident
care or service
• Implemented emergency purchasing action to onboard a consulting firm to
assist with mitigation (Phigenics)
• Emptied the main entrance fountain

August 27, 2015 (Thursday)


• IDPH continues multiple, daily communications with CDC
• Joint IDPH/IDVA press release announcing eight confirmed cases, no known
deaths
• Four of the eight treated at Blessing Hospital and have returned to the
IVHQ with four remaining hospitalized
• IVHQ posts educational material at every Nurses’ Station
• 20-30 persons associated with the IVHQ are being evaluated for respiratory
illnesses (some at home, some at the hospital, some staff)
• One confirmed community case of Legionella in an Adams County resident.
Case not known to be linked to the IVHQ

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• State of Illinois Rapid Electronic Notification (SIREN) Alert issued to local health
departments (LHDs), providers, hospital infection control nurses, and hospital
emergency departments statewide
• IDPH EH issues interim guidelines for potable water restrictions at IVHQ
• Recommendations focused on appropriate use and disinfection of ice
machines, dishwashers, and steam tables in food service
• To expedite UAT turnaround time, IVHQ sends urine specimens for Legionella
testing to Memorial Hospital in Hannibal, MO
• Plans for IVHQ to take down cooling tower the following day along with plans to
manual clean and flush in accordance with ASHRAE 188 Standard and refilling
with appropriate sanitizers and biological control chemicals
• CDC indicates concurrence with this plan on a call

August 28, 2015 (Friday)


• IDPH continues multiple, daily communications with CDC
• IDVA/IDPH news release of two deaths, 23 confirmed cases
• IDPH Interview with Illinois Radio Network on Legionnaires’ disease on general
health questions, signs, symptoms, who is most vulnerable, and how to stop it
from spreading
• In addition to taking vitals every four hours for skilled nursing residents, IVHQ
increased vital signs checks to every four hours for residents in the independent
living facilities (domiciliaries)
• GO Chief Operating Officer emails IDPH Director indicating that Governor has
been personally notified of the deaths
• Cooling tower cleaned, refilled, and back online. Increased operational
disinfectant levels to 15ppm bromine
• Two laboratory confirmed cases in surrounding community

August 29, 2015 (Saturday)


• IDPH continues multiple, daily communications with CDC
• Conference calls among IDPH, IDVA, ACHD, GO, and CDC
• IVHQ began taking vitals on skilled units every two hours

August 30, 2015 (Sunday)


• IDPH continues multiple, daily communications with CDC
• IEPA assessment of water samples

August 31, 2015 (Monday)


• IDPH continues multiple, daily communications with CDC
• IDVA, ACHD, IVHQ, IEPA, and Garrett-Callahan, IVHQ’s chemical treatment
supplier, discuss sanitizing the potable water supply. Samples of the municipal
water supply and the cooling tower taken for analysis

September 1, 2015 (Tuesday)


• IDPH continues multiple, daily communications with CDC
• Legislative conference call hosted by IDPH and IDVA

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• IDVA/IDPH press release issued – seven deaths and 39 confirmed cases
• US Senator Kirk’s office receives an update on IVHQ

September 2, 2015 (Wednesday)


• IDPH continues multiple, daily communications with CDC
• News release – four confirmed cases (including one death) unconnected to IVHQ
• IVHQ orders Pall filters capable of trapping Legionella bacteria for showers
• IDVA speaks with USDVA to alert them to the emergency project beginning at
IVHQ to request funds for the Veteran Home Reconstruction Grant

September 3, 2015 (Thursday)


• IDPH continues multiple, daily communications with CDC
• IDVA, IDPH, and CDC brief US Senator Durbin on IVHQ

September 4, 2015 (Friday)


• IDVA initiates the contract with Phigenics for water remediation
• IDVA and IDPH brief US Senator Kirk on IVHQ

September 8, 2015
• IDVA hyper chlorinated hot and cold water
• Cooling Tower cleaned again

September 9, 2015
• IDVA hyper chlorinated hot and cold water

September 11, 2015


• IVHQ changed protocols for vitals and began checking every shift

September 18, 2015


• Initiated installation of Pall Filters on showers/tubs

September 30, 2015


• IVHQ shuts down the cooling tower for the season

October 1, 2015
• Emergency declared by CDB for remediation work

October 5, 2015
• Engineering firm for CDB emergency project mobilized

October 6, 2015
• Contractor for CDB emergency project mobilized

October 23, 2015


• Temporary water treatment plant installed in place and operating in Quincy at
Locust street site

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• 6-bay garage was identified as the future location of the new water treatment
facility

October 26, 2015


• Vendor begins installing point of use mixing valves at all points of use campus-
wide

December 17, 2015


• Water Treatment Facility design is complete and provided to EPA for permitting
of piping

December 31, 2015


• CDC issues Epi-Aid 2015-037 Trip Report: “Undetermined source of an
healthcare-associated outbreak of Legionnaire’s disease – Illinois, 2015”

X. Appendices
A. CDC Trip Reports

Date Link
http://dph.illinois.gov/sites/default/files/publications/cdc-trip-
December 31, 2015
reportquincyil12.31.15.pdf
http://dph.illinois.gov/sites/default/files/publications/cdc-trip-
June 26, 2017
reportquincyil06.26.17.pdf
http://dph.illinois.gov/sites/default/files/publications/cdc-trip-
January 4, 2018
reportquincyil1.4.18.pdf

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B. Case Summary Table

Illinois Veterans Home Quincy – all legionellosis cases (LD + PF), 2015-present
2015 2016 2017 2018

Residents 47 (35 LD + 12 PF) 6 5 4

Staff 6 (LD) 0 1 0

Total cases 53 6 6 4

Dates of
July 24 – Sept 18 July 14 – Dec 10 March 9 – Nov 20 Feb 8 – Feb 15
symptom onset

- - - - -

Fatalities 12 (11 LD + 1 PF) 0 1 0

LD = Legionnaires’ disease
PF = Pontiac fever

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C. Geographic Distribution of Legionellosis in Illinois, 2014-2016

32

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